Früh vs. spät: Gibt es den optimalen Zeitpunkt für einen chirurgischen Eingriff am Bandscheibenvorfall der lumbalen Wirbelsäule? Ergebnisse einer prospektiven matched pair-Kohortenstudie

Zusammenfassung

Fragestellung: Ziel der monozentrischen prospektiven matched pair-Kohortenstudie war die Identifikation eines möglichen Unterschieds im inhaltlichen Outcome nach Operation am lumbalen Bandscheibenvorfall in Abhängigkeit des Zeitpunktes der chirurgischen Intervention.

Material und Methoden: Betrachtet wurden 2 × 78 im Verhältnis 1:1 post-hoc gematchte Patienten mit lumbalem Bandscheibenvorfall. Die Kohortierung erfolgte anhand der konservativen Vorbehandlungsdauer (Kohorte 1: maximal 12 Wochen und Kohorte 2: 12–36 Wochen). Der primäre klinische Endpunkt wurde entlang des ODI definiert als dessen 6-monatige Änderung post-prä OP; zwischen den beiden Patienten eines matched pairs wurde die intra-pair-Abweichung als Effektmaß bestimmt.

Ergebnisse: Es ließ sich bei medianen 6-monatigen ODI-Anstiegen von 36% vs. 32% kein statistisch signifikanter Unterschied zwischen den Kohorten im primären Endpunkt zeigen (p=0,649).

Schlussfolgerung: Der frühere Zeitpunkt der operativen Intervention führte nicht zu einem signifikant überlegenen Therapieergebnis.

Abstract

Purpose: To determine whether the clinical outcome of primary spinal surgery for lumbar disc herniation is better than the result of secondary surgical intervention after conservative treatment.

Materials and Methods: The study included 2×78 patients matched post hoc in a ratio of 1:1. The patients were divided according to the duration of their prior treatment (cohort 1: max. 12 weeks and cohort 2: 12–36 weeks). We examined the level of disability one day before and 6 months after surgery with percentage change in ODI, defined as primary endpoint and its intra-pair difference specified as effect measure.

Results: In the course of 6 months the increase in ODI was 36% for cohort 1 and 32% for cohort 2. No significant difference was found in the effect measure of the primary endpoint (p=0.649).

Discussion: The findings indicate that the result of early surgical intervention in lumbar disc herniation is not significantly superior to the outcome of late surgery after failed conservative therapy.

Schlüsselwörter

Bandscheibenvorfall - Rückenschmerz - spinale Chirurgie - Zeitpunkt

Key words

lumbar disc herniation - spine surgery - low back pain - timing

• Literatur

• 1 Akagi R, Aoki Y, Ikeda Y et al. Comparison of early and late surgical intervention for lumbar disc herniation: is earlier better?. J Orthop Sci 2010; 15: 294-298
• 2 Andersson GB, Brown MD, Dvorak J et al. Consensus Summary on the Diagnosis and Treatment of Lumbar Disc Herniation. Funct Neurol 2004; 19: 43-49
• 3 Atlas SJ, Keller RB, Chang Y et al. Surgical and nonsurgical management of sciatica secondary to a lumbar disc herniation: five-year outcomes from the Maine Lumbar Spine Study. Spine (Phila Pa 1976) 2001; 26: 1179-1187
• 4 Atlas SJ, Keller RB, Wu YA et al. Long-term outcomes of surgical and nonsurgical management of sciatica secondary to a lumbar disc herniation: 10 year results from the maine lumbar spine study. Spine (Phila Pa 1976) 2005; 30: 927-935
• 5 Awad JN, Moskovich R. Lumbar disc herniations: surgical versus nonsurgical treatment. Clin Orthop Relat Res 2006; 443: 183-197
• 6 Barrios C, Ahmed M, Arrotegui JI et al. Clinical factors predicting outcome after surgery for herniated lumbar disc: An epidemiological multivariate analysis. J Spinal Disord 1990; 3: 205-209
• 7 Blazhevski B, Filipche V, Cvetanovski V et al. Predictive value of the duration of sciatica for lumbar discectomy. Prilozi 2008; 29: 325-335
• 8 Boerner J. Psychiatrische und psychosomatische Aspekte chronischer Wirbelsäulenerkrankungen. In: Börm W, Meyer F. Hrsg Spinale Neurochirurgie. Operatives Management von Wirbelsäulenerkrankungen. Schattauer. 2009
• 9 Börm W. Lumbaler Bandscheibenvorfall. In: Börm W, Meyer F. Hrsg Spinale Neurochirurgie. Operatives Management von Wirbelsäulenerkrankungen. Schattauer. 2009
• 10 Börm W, Steiger H, Papavero L et al. Leitlinie Lumbaler Bandscheibenvorfall. 2006 DGNC
• 11 Buttermann GR. Treatment of lumbar disc herniation: epidural steroid injection compared with discectomy. A prospective, randomized study. J Bone Joint Surg Am 2004; 86-A: 670-679
• 12 Carragee EJL, Kim DH. A prospective analysis of magnetic resonance imaging findings in patients with sciatica and lumbar disc herniation. Correlation of outcomes with disc fragment and canal morphology. Spine (Phila Pa 1976) 1997; 22: 1650-1660
• 13 Cassidy JD, Côté P, Carroll LJ et al. Incidence and course of low back pain episodes in the general population. Spine (Phila Pa 1976) 2005; 30: 2817-2823
• 14 Chou R, Qaseem A, Snow V et al. Clinical Efficacy Assessment Subcommittee of the American College of Physicians; American College of Physicians; American Pain Society Low Back Pain Guidelines Panel. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007; 147: 478-491
• 15 Chou R, Atlas SJ, Stanos SP et al. Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine (Phila Pa 1976) 2009; 34: 1078-1093
• 16 Danon-Hersch N, Samartzis D, Wietlisbach V et al. Appropriateness Criteria for Surgery Improve Clinical Outcomes in Patients With Low Back Pain and/or Sciatica. Spine (Phila Pa 1976) 2010;
• 17 Dauch WA, Fasse A, Brücher K et al. Predictors of treatment success after microsurgical operation of lumbar intervertebral disk displacement. Zentralbl Neurochir 1994; 55: 144-155
• 18 Dewing CB, Provencher MT, Riffenburgh RH et al. The outcomes of lumbar microdiscectomy in a young, active population: correlation by herniation type and level. Spine (Phila Pa 1976). 2008; 33: 33-38
• 19 Deyo RA, Mirza SK. Trends and variations in the use of spine surgery. Clin Orthop Relat Res 2006; 443: 139-146
• 20 Deyo RA, Weinstein JN. Low back pain. N Engl J Med 2001; 344: 363-370
• 21 Donceel P, Du Bois M. Predictors for work incapacity continuing after disc surgery. Scand J Work Environ Health 1999; 25: 264-271
• 22 Downie A, Williams CM, Henschke N et al. Red flags to screen for malignancy and fracture in patients with low back pain: systematic review. BMJ 2013; 347: f7095
• 23 Dvorak J, Gauchat MH, Valach L. The outcome of surgery for lumbar disc herniation. I. A 4–17 years’ follow-up with emphasis on somatic aspects. Spine (Phila Pa 1976) 1988; 13: 1418-1422
• 24 Fairbank J. Prolapsed intervertebral disc. BMJ 2008; 336: 1317-1318
• 25 Fisher C, Noonan V, Bishop P et al. Outcome evaluation of the operative management of lumbar disc herniation causing sciatica. J Neurosurg 2004; 100 (4 Suppl Spines) 317-324
• 26 Folman Y, Shabat S, Catz A et al. Late results of surgery for herniated lumbar disk as related to duration of preoperative symptoms and type of herniation. Surg Neurol 2008; 70: 398-401 discussion 401–402
• 27 Gaetani P, Aimar E, Panella L et al. Surgery for herniated lumbar disc disease: factors influencing outcome measures. An analysis of 403 cases. Funct Neurol 2004; 19: 43-49
• 28 George C. The six-month incidence of clinically significant low back pain in the Saskatchewan adult population. Spine (Phila Pa 1976) 2002; 27: 1778-1782
• 29 Gerbershagen U. Organisierte Schmerzbehandlung. Eine Standortbestimmung. Der Internist 1986; 27 459-469
• 30 Gibson JN, Waddell G, Grant IC. Surgery for degenerative lumbar spondylosis. Cochrane Database Syst Rev. 2000; CD001352. Review. Update in: Cochrane Database Syst Rev 2005;(2):CD001352
• 31 Gibson JN, Waddell G. Surgical interventions for lumbar disc prolapse: updated Cochrane Review. Spine (Phila Pa 1976) 2007; 32: 1735-1747
• 32 Grochulla F, Ben Ghezala K. Rückenschmerz und degenerative Bandscheibenerkrankung. In: Börm W, Meyer F. Hrsg Spinale Neurochirurgie. Operatives Management von Wirbelsäulenerkrankungen. Schattauer. 2009
• 33 Hakelius A. Prognosis in sciatica. A clinical follow-up of surgical and non-surgical treatment. Acta Orthop Scand Suppl 1970; 129: 1-76
• 34 Häkkinen A, Ylinen J, Kautiainen H et al. Does the outcome 2 months after lumbar disc surgery predict the outcome 12 months later?. Disabil Rehabil 2003; 25: 968-972
• 35 Häkkinen A, Kautiainen H, Järvenpää S et al. Changes in the total Oswestry Index and its ten items in females and males pre- and post-surgery for lumbar disc herniation: a 1-year follow-up. Eur Spine J 2007; 16: 347-352
• 36 Hestbaek L, Leboeuf-Yde C, Manniche C. Low back pain: what is the long-term course? A review of studies of general patient populations. Eur Spine J 2003; 12: 149-165 Epub 2003 Jan 28
• 37 Hurme M, Alaranta H. Factors predicting the result of surgery for lumbar intervertebral disc herniation. Spine (Phila Pa 1976) 1987; 12: 933-938
• 38 Ito T, Takano Y, Yuasa N. Types of lumbar herniated disc and clinical course. Spine (Phila Pa 1976) 2001; 26: 648-651
• 39 Jackson RK. The long-term effect of wide laminectomy for lumbar disc excision. A review of 130 patients. J Bone Joint Surg Am 1971; 53: 609-616
• 40 Jacob T. Low back pain incident episodes: a community-based study. Spine J 2006; 6: 306-310
• 41 Jänig W, May A. Schmerzentstehung und Chronifizierung. In: Hildebrandt J, Pfingsten M. Hrsg Rückenschmerz und Lendenwirbelsäule. Urban & Fischer; 2012
• 42 Jansson KA, Németh G, Granath F et al. Health-related quality of life in patients before and after surgery for a herniated lumbar disc. J Bone Joint Surg Br 2005; 87: 959-964
• 43 Jönsson B. Patient-related factors predicting the outcome of decompressive surgery. Acta Orthop Scand Suppl 1993; 251: 69-70
• 44 Junge A, Dvorak J, Ahrens S. Predictors of bad and good outcomes of lumbar disc surgery. A prospective clinical study with recommendations for screening to avoid bad outcomes. Spine (Phila Pa 1976) 1995; 20: 460-468
• 45 Junge A, Fröhlich M, Ahrens S et al. Predictors of bad and good outcome of lumbar spine surgery. A prospective clinical study with 2 years’ follow up. Spine (Phila Pa 1976) 1996; 21: 1056-1064 discussion 1064-1065
• 46 Karaharju EO, Alho A, Laasonen E. Herniated lumbar disc: postoperative condition and correlation with preoperative and operative findings. Ann Chir Gynaecol Fenn 1974; 63: 53-56
• 47 Kast E, Antoniadis G, Richter HP. Epidemiology of disk surgery in Germany. Zentralbl Neurochir 2000; 61: 22-25
• 48 Kitze K, Winkler D, Günther L et al. Preoperative predictors for the return to work of herniated disc patients. Zentralbl Neurochir 2008; 69: 7-13
• 49 Klauber J, Geraedts M, Friedrich J et al. Hrsg Krankenhausreport 2013. Schattauer. 2013;
• 50 Kleinstueck FS, Fekete T, Jeszenszky D et al. The outcome of decompression surgery for lumbar herniated disc is influenced by the level of concomitant preoperative low back pain. Eur Spine J 2011; 20: 1166-1173
• 51 Koes BW, van Tulder MW, Peul WC. Diagnosis and treatment of sciatica. BMJ 2007; 334: 1313-1317
• 52 Krämer J, Theodoris T, Krämer R. Operative Verfahren. In: Hildebrandt J, Pfingsten M. Hrsg Rückenschmerz und Lendenwirbelsäule. Urban & Fischer; 2012
• 53 Krämer J, Ludwig J. Surgical treatment of lumbar disc herniation. Indication and methods. Der Orthopäde 1999; 28: 579-584
• 54 Kreiner DS, Hwang SW, Easa JE et al. An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy. Spine J 2014; 14: 180-191
• 55 Lewis PJ, Weir BK, Broad RW et al. Long-term prospective study of lumbosacral discectomy. J Neurosurg 1987; 67: 49-53
• 56 Lin CW, Haas M, Maher CG et al. Cost-effectiveness of guideline-endorsed treatments for low back pain: a systematic review. Eur Spine J 2011; 20: 1024-1038
• 57 Loupasis GA, Stamos K, Katonis PG et al. Seven- to 20-year outcome of lumbar discectomy. Spine (Phila Pa 1976) 1999; 24: 2313-2317
• 58 Lühmann D, Burkhardt-Hammer T, Borowski C et al. Minimal-invasive Verfahren zur Behandlung des Bandscheibenvorfalls. HTA-Bericht 17. Deutsche Agentur für Health Technology Assessment des Deutschen Instituts für Medizinische Dokumentation und Information 2005;
• 59 Lühmann D, Raspe H. Operative Eingriffe an der lumbalen Wirbelsäule bei bandscheibenbedingten Rücken- und Beinschmerzen. Eine Verfahrensbewertung 2003;
• 60 Luijsterburg PA, Verhagen AP, Braak S et al. Neurosurgeons’ management of lumbosacral radicular syndrome evaluated against a clinical guideline. Eur Spine J 2004; 13: 719-723
• 61 Luijsterburg PA, Verhagen AP, Ostelo RW et al. Effectiveness of conservative treatments for the lumbosacral radicular syndrome: a systematic review. Eur Spine J 2007; 16: 881-899
• 62 Lurie JD, Tosteson TD, Tosteson AN et al. Surgical versus nonoperative treatment for lumbar disc herniation: eight-year results for the spine patient outcomes research trial. Spine (Phila Pa 1976) 2014; 39: 3-16
• 63 Marshall WJ, Schorstein J. Factors affecting the results of surgery for prolapsed lumbar intervertebral disc. Scott Med J 1968; 13: 38-42
• 64 McCulloch JA. Focus issue on lumbar disc herniation: macro- and microdiscectomy. Spine (Phila Pa 1976) 1996; 21 (24 Suppl) 45S-56S
• 65 McGregor AH, Doré CJ, Morris TP et al. ISSLS prize winner: Function After Spinal Treatment, Exercise, and Rehabilitation (FASTER): a factorial randomized trial to determine whether the functional outcome of spinal surgery can be improved. Spine (Phila Pa 1976) 2011; 36: 1711-1720
• 66 Müller R. Wie lässt sich die Chronifizierung lumbaler Rückenschmerzen verhindern?. Manuelle Medizin 2010; 48: 260-266
• 67 Nachemson A. Work for all. For those with low back pain as well. Clin Orthop Relat Res 1983; 77-85
• 68 Nachemson AL. Advances in low-back pain. Clin Orthop Relat Res 1985; 266-278
• 69 Nakagawa H, Kamimura M, Takahara K et al. Optimal duration of conservative treatment for lumbar disc herniation depending on the type of herniation. J Clin Neurosci 2007; 14: 104-109
• 70 Ng LC, Sell P. Predictive value of the duration of sciatica for lumbar discectomy. A prospective cohort study. J Bone Joint Surg Br 2004; 86: 546-549
• 71 Nygaard OP, Kloster R, Solberg T. Duration of leg pain as a predictor of outcome after surgery for lumbar disc herniation: a prospective cohort study with 1-year follow up. J Neurosurg 2000; 92 (2 Suppl) 131-134
• 72 Nygaard OP, Romner B, Trumpy JH. Duration of symptoms as a predictor of outcome after lumbar disc surgery. Acta Neurochir (Wien) 1994; 128: 53-56
• 73 Omidi-Kashani F, Ghayem Hasankhani E, Kachooei AR et al. Does duration of preoperative sciatica impact surgical outcomes in patients with lumbar disc herniation?. Neurol Res Int 2014; 2014: 565189
• 74 Osterman H, Seitsalo S, Karppinen J et al. Effectiveness of microdiscectomy for lumbar disc herniation: a randomized controlled trial with 2 years of follow-up. Spine (Phila Pa 1976) 2006; 31: 2409-2414
• 75 Peul WC, van Houwelingen HC, van den Hout WB et al., Leiden The Hague Spine Intervention Prognostic Study Group . Surgery versus prolonged conservative treatment for sciatica. N Engl J Med 2007; 356: 2245-2256
• 76 Peul WC, van den Hout WB, Brand R et al. Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results of a randomised controlled trial. Prognostic Study Group. BMJ 2008; 336: 1355-1358
• 77 Postacchini F. Results of surgery compared with conservative management for lumbar disc herniations. Spine (Phila Pa 1976) 1996; 21: 1383-1387
• 78 Postacchini F. Management of herniation of the lumbar disc. J Bone Joint Surg Br 1999; 81: 567-576
• 79 Quigley MR, Bost J, Maroon JC et al. Outcome after microdiscectomy: results of a prospective single institutional study. Surg Neurol 1998; 49: 263-267 discussion 267–268
• 80 Quon JA, Sobolev BG, Levy AR et al. The effect of waiting time on pain intensity after elective surgical lumbar discectomy. Spine J 2013;
• 81 Raspe H. Robert Koch-Institut Hrsg Rückenschmerzen. Gesundheitsberichterstattung des Bundes. Heft 53. RKI; Berlin: 2012
• 82 Reichel H, Eysel P. Lumbaler Bandscheibenvorfall – Konservative oder Operative Behandlung. In Reichel H, Zwipp H, Hein W. Hrsg Wirbelsäulenchirurgie. Standortbestimmung und Trends. Steinkopff Verlag Darmstadt; 2000
• 83 Rihn JA, Hilibrand AS, Radcliff K et al. Duration of symptoms resulting from lumbar disc herniation: effect on treatment outcomes: analysis of the Spine Patient Outcomes Research Trial (SPORT). J Bone Joint Surg Am 2011; 93: 1906-1914
• 84 Roslund J. Indications for lumbar disk surgery: factors influencing the long-term prognosis. Stockholm: 1974. ISBN: 9789172220966
• 85 Rothoerl RD, Woertgen C, Brawanski A. When should conservative treatment for lumbar disc herniation be ceased and surgery considered?. Neurosurg Rev 2002; 25: 162-165
• 86 Sabnis AB, Diwan AD. The timing of surgery in lumbar disc prolapse: A systematic review. Indian J Orthop 2014; 48: 127-135
• 87 Sandkühler J. Learning and memory in pain pathways. Pain 2000; 88: 113-118
• 88 Schmidt CO, Raspe H, Pfingsten M et al. Back pain in the German adult population: prevalence, severity, and sociodemographic correlates in a multiregional survey. Spine (Phila Pa 1976) 2007; 32: 2005-2011
• 89 Schoeggl A, Maier H, Saringer W et al. Outcome after chronic sciatica as the only reason for lumbar microdiscectomy. J Spinal Disord Tech 2002; 15: 415-419
• 90 Schoenfeld AJ, Weiner BK. Treatment of lumbar disc herniation: Evidence-based practice. Int J Gen Med 2010; 3: 209-214
• 91 Shiri R, Solovieva S, Husgafvel-Pursiainen K et al. Incidence of nonspecific and radiating low back pain: follow-up of 24–39-year-old adults of the Young Finns Study. Arthritis Care Res (Hoboken) 2010; 62: 455-459
• 92 Silverplats K, Lind B, Zoëga B et al. Clinical factors of importance for outcome after lumbar disc herniation surgery: long-term follow-up. Eur Spine J 2010; 19: 1459-1467
• 93 Solberg T, Johnsen LG, Nygaard ØP et al. Can we define success criteria for lumbar disc surgery? Estimates for a substantial amount of improvement in core outcome measures. Acta Orthop 2013; 84: 196-201
• 94 Sørensen LV, Mors O, Skovlund O. A prospective study of the importance of psychological and social factors for the outcome after surgery in patients with slipped lumbar disk operated upon for the first time. Acta Neurochir (Wien) 1987; 88: 119-125
• 95 Spangfort EV. The lumbar disc herniation. A computer-aided analysis of 2,504 operations. Acta Orthop Scand Suppl 1972; 142: 1-95
• 96 Spengler DM, Freeman C, Westbrook R et al. Low-back pain following multiple lumbar spine procedures. Failure of initial selection?. Spine (Phila Pa 1976) 1980; 5: 356-360
• 97 Stienen MN, Cadosch D, Hildebrandt G et al. The lumbar disc herniation – management, clinical aspects and current recommendations. Praxis (Bern 1994) 2011; 100: 1475-1485
• 98 Strayer A. Lumbar spine: common pathology and interventions. Review. J Neurosci Nurs 2005; 37: 181-193
• 99 Surin VV. Duration of disability following lumbar disc surgery. Acta Orthop Scand 1977; 48: 466-471
• 100 Tal A. Rückenschmerzen im Alltag bestimmen. Assessment: Oswestry Disability Questionnaire. Physiotherapie 2009; 7-8 09 46-47
• 101 Teplick JG, Haskin ME. Spontaneous regression of herniated nucleus pulposus. AJR Am J Roentgenol 1985; 145: 371-375
• 102 Thomé C, Barth M, Scharf J et al. Outcome after lumbar sequestrectomy compared with microdiscectomy: a prospective randomized study. J Neurosurg Spine 2005; 2: 271-278
• 103 Trief PM, Grant W, Fredrickson B. A prospective study of psychological predictors of lumbar surgery outcome. Spine (Phila Pa 1976) 2000; 25: 2616-2621
• 104 Vader JPL, Porchet F, Larequi-Lauber T et al. Appropriateness of surgery for sciatica: reliability of guidelines from expert panels. Spine (Phila Pa 1976) 2000; 25: 1831-1836
• 105 Vroomen PC, de Krom MC, Knottnerus JA. When does the patient with a disc herniation undergo lumbosacral discectomy?. J Neurol Neurosurg Psychiatry 2000; 68: 75-79
• 106 Wanke I, Meyer F. Bildgebende Diagnostik in der spinalen Neurochi­rurgie. In: Börm W, Meyer F. Hrsg Spinale Neurochirurgie. Operatives Management von Wirbelsäulenerkrankungen. Schattauer. 2009
• 107 Waxman R, Tennant A, Helliwell P. A prospective follow-up study of low back pain in the community. Spine (Phila Pa 1976) 2000; 25: 2085-2090
• 108 Weber H. Lumbar disc herniation. A prospective study of prognostic factors including a controlled trial. Part I. J Oslo City Hosp 1978; 28: 33-61
• 109 Weber H. Lumbar disc herniation. A controlled, prospective study with ten years of observation. Spine (Phila Pa 1976) 1983; 8: 131-140
• 110 Weber H. The natural history of disc herniation and the influence of intervention. Spine (Phila Pa 1976) 1994; 19: 2234-2238 discussion 2233
• 111 Weinstein JN, Lurie JD, Tosteson TD et al. Surgical vs. nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT) observational cohort. JAMA 2006; 296: 2451-2459
• 112 Yorimitsu E, Chiba K, Toyama Y et al. Long-term outcomes of standard discectomy for lumbar disc herniation: a follow-up study of more than 10 years. Spine (Phila Pa 1976) 2001; 26: 652-657